When Less Becomes More: Life and Losses without the 'Roids'?

Abstract

Corticosteroids are known to have anti-inflammatory and immunosuppressive effects and are useful to prevent acute rejection post-transplant.³ However, they are not without adverse effects. Chronic steroid use is associated with a wide range of complications including weight gain, hyperglycemia, osteoporosis, cataract, cardiovascular disease, and infections, and is a risk factor for premature death.⁴ In view of these complications, there had been a concerted effort to minimize long-term corticosteroids use. Many centers have advocated for steroid minimization or early withdrawal, often within days after transplantation. Others have been concerned regarding the short-term risks of steroid withdrawal, including acute rejection, leading to early allograft loss. Globally, the patterns of long-term steroid use vary considerably between regions, and within regions according to high-risk recipient or donor characteristics. Notably, most trials of early steroid withdrawal have excluded patients at increased risk of adverse allograft outcome, such as presensitized patients and those who have developed delayed graft function (DGF) post-transplant; both are known correlates with acute rejection and allograft loss.⁵ In the absence of trial-based evidence to inform policy and clinical practices in the high-risk settings, the next best option is to rely on observational data, often collected for completely different purposes, and multiple analyses (including subgroups) are performed to explain why some hypotheses hold or why they may be wrong.